Democratizing Surgery Part 2: How Verb is Provoking a Surgical Revolution.

*Note-Before proceeding, be sure to read Part 1 of this article series.

Last week I wrote an article about some of my favorite topics: marketing, psychology, and disruptive technology.

The subject was Verb Surgical, the hybrid child between Johnson and Johnson's Ethicon and Google's Verily Life Sciences, and their vision of "democratizing surgery".

In it, I shared how Verb is tearing into the surgical universe and creating a wormhole into a new category.

Prophecy is many times the principal cause of the events foretold.

The Rocket Ship

"The business enterprise has two–and only two–basic functions: marketing and innovation." - Peter Drucker

You have to hand it to the guy, Drucker is one of the few people that can be called a "business guru" for a reason.

The only functions of business are marketing and innovation because that is what produces results.

All other functions are costs. 

Verb has the innovation part in the works, but that's the rocket they're building.

Marketing can be likened to the innovative ways of developing the right fuel and thrusters to launch a rocket with enough propulsion to make it into space.

As we've seen in medical technology adoption, it doesn't matter what you're creating. Without the right combination of oxygen and fuel plus well designed thrusters, that innovative rocket you built isn't going anywhere.

The second Phase of the Law of Advertising (22 Immutable Laws of Marketing) is about the rise of the company that pioneered the new category. 

So let's flip the surgical universe on it's side and go deeper into the wormhole.

Down the Wormhole

"In order to become painting, the universe seen by the artist had to become a private one created by himself." - Andre Malraux

When Verb Surgical takes this violent step from the surgical robotic universe and into a liberated future of digital surgery, something remarkable happens; the robotic world vacuums.

That means the world of robotics adapts and evolves into a new category, Digital Surgery, where robotics is only one part of the surgery.

The vacuum might be like a ball perched on the side of a hill.

If Verb gives the vacuum a big enough nudge, it might start rolling down the hill and we would not be able to stop it.

Verb would release a huge bubble of energy that expands at the speed of light, leaving a vast trail of destruction in its wake to companies that cannot evolve fast enough.

Over time, that could be so bad that every company would be torn apart during the apocalypse.

Too dramatic?

What did Netflix do to Blockbuster and Hollywood?

What did Amazon do to Borders and Barnes & Nobles?

Natural selection, whether in business or mother nature, has no mercy for those who cannot adapt and evolve.

Riding the Wave of the Market

In his book Crossing the Chasm, Geoffrey Moore introduced the Technology Adoption Lifecycle and the Law of Diffusion of Innovation. 

Surgeons all sit at various places at various times on this scale, but what the law of diffusion of innovation tells us is that if you want mass-market success or mass-market acceptance of an idea, you can't have it right away.

You must achieve this tipping point between 15 and 18 percent (called "crossing the chasm") market penetration, and then the system tips. 

Intuitive Surgical pioneered robotics, and that's why they own the word "robot" in a surgeon's subconscious mind.

It isn't an accident that they also have the largest marketshare.

If Verb Surgical creates a mass movement among surgeons strong enough, it will vacuum other companies through the wormhole.

Phase 2 of the Law of Advertising has historically shown that time gives rise to the company that pioneered the new category.

Now, why do I depict Verb Surgical increasing in size as this vacuum occurs?

Let's microscope in and see.

All the other robotic companies (and possibly other medtech companies) will begin to evolve into the digital surgery age.

As they come out of the wormhole vacuum, their collective force at the beginning as well as later when other companies trickle in will push Verb up the adoption curve.

The momentum from increased marketing budgets spent by other companies evolving to compete and protect against losing their customers causes this.

As economics and decision theory have taught us, loss aversion is a cognitive bias that is quite strong.

People (and companies) have a tendency to act on avoiding losses versus acquiring equivalent gains.

With robotics, all the larger players (Medtronic, Zimmer Biomet, Globus, Brainlab) have either acquired or launched their own robotics program.

The threat of losing customers if one of the robotic startups begins to produce tools and implants is to strong.

As the wormhole vacuums, companies shoot out, adding momentum to companies ahead of them as well as Verb.

This momentum further validates the market, strengthening Verb as the category leader and consequently growing Verb's market share.

This is exactly what will happen with digital surgery, but it's on Verb's shoulders.

It can either be a surgical renaissance like robotics, or just another fad with no clinical value to back it (e.g. surgery's most expensive joke- laser spine surgery).

Marketing strategies will multiply in numbers and strength as companies rush to be relevant and innovate, further validating the market.

Up Verb goes, growing in marketshare size and weight, as the collective marketing force of the market pushes them up the adoption curve.

More importantly, associating the word "Verb" to be synonymous with "Digital Surgery".

Once you own the code word, you've won the real battle of marketing, not of products but perception.

So when I say "streaming movies and shows", one company appears in your mind.

When I say "order online and receive overnight", one company appears in your mind.

I was groomed by Mazor Robotics, yet when someone says "robotic surgery" one company comes to my mind, and that's not Mazor because they weren't the company that pioneered the category and successfully leveraged marketing.

This isn't just a battle of geographic or financial marketshare.

This is about a campaign being waged to own as much marketshare in surgeons' minds as possible.

Marketing isn't about a battle of products; it's a battle of perceptions.

Moving Surgeons in Mind and Body

Trust only movement. Life happens at the level of events, not of words. Trust movement. ~Alfred Adler

Competing over physical marketshare is one thing, but the marketshare of the mind?

That's something that requires a more surgical approach (*pun intended).

Normalization Process Theory (NPT) is a sociological theory of the implementation, embedding, and integration of new technologies and organizational innovations.

It focuses attention on agentic contributions – the things that individuals and groups do to operationalize new or modified modes of practice as they interact with dynamic elements of their environments.

Stanford University Psychologist Albert Bandura developed Agentic Theory as a social cognition theory that views people as self-organizing, proactive, self-reflective and self-regulating as times change.

An agentic perspective states that we are not merely reactive organisms shaped by environmental forces or driven by inner impulses. 

In other words, human beings intuitively and proactively evolve and adapt accordingly.

When surgeons deliberately initiate and seek to sustain a sequence of events to bring it into operation, it involves three things:

• Implementation
• Embedding
• Integration

The dynamics of implementation are complex, but NPT simplifies things by focusing attention on the mechanisms through which participants, in our case surgeons, invest and contribute to them.

Simply put, here's how that framework looks broken down:

1. Surgeons engage with a group of activities around new ways of thinking, acting, and organizing.
2. These activities eventually become routinely embedded into already existing environments and networks of socially patterned knowledge and practices. [1]

Now think about that for a moment.

Doing new things and thinking new thoughts that become part of something that already existed, thus evolving it.

In a paper published under a creative commons license, May and colleagues describe how, since 2006, NPT has undergone three iterations.[2]: Objects, Agents, and Contexts.

For Verb's case, we just need to focus on the third and latest iteration of the theory; contexts.

Contexts

The theory of "Contexts" developed the analysis of agentic contributions by offering an account of centrally important structural and cognitive resources on which agents draw as they take action [3] 

Agentic contribution is a social cognition theory perspective in which people are producers as well as products of social systems.

Here, the dynamic elements of social contexts are experienced by agents as:

• Capacity (the social structural resources, that they possess, including informational resources, social norms, and roles)
• Potential (the social cognitive resources that surgeons possess, including knowledge and beliefs, and individual intentions and shared commitments)

These resources are mobilized by agents (surgeons) when they invest in the ensembles of practices (robotics, artificial intelligence, advanced imaging, big data) that are the objects of implementation.

For Verb Surgical, that implementation is Digital Surgery.

Infograph Source: Santosh Iyer

What is a Verb?

VERB- a word used to describe an action, state, or occurrence, and forming the main part of the predicate of a sentence, such as hear, become, happen.

Verb chose it's name because it's about action.

They're action oriented, and want to take actions that change the world.

Thus, they're "Verb" Surgical.

Between a noun, and a direct object.

Surgeon and patient.

There sit's Verb.

They're ACTION oriented, and it's about actions that change the world.

As CEO Scott Huennekens puts it, "what better word than Verb?"

Actions Speak Louder than Attitudes

“Sow a thought and you reap an action; Sow an act and you reap a habit; Sow a habit and you reap a character; Sow a character and you reap a destiny.” - Ralph Waldo Emerson

Dr. Fisayo Ositelu is a dear friend and intellectual sparring partner.

In my eyes he is living proof of the American dream.

As one of Nigeria's top students, he was accepted to study Molecular and Cellular Biology at the prestigious Johns Hopkins University, then went to Stanford for his MD/MBA, and has now taken his talents to a Silicon Valley based financial tech startup.

In discussing the psychology behind marketing and advertising, he illuminated a valuable insight:

"Omar, too much of marketing today focuses on just the attitude. What is more valuable is focusing on driving action"

Dr. Ositelu's keen observation illuminates a key piece of Verb's marketing strategy.

Changing an attitude is vital, but action must be enabled to really engrain the newly formed attitude.

Dr. Ositelu explains that "Action changes attitude faster than attitude changes action".

Think about it.

If you just straighten your posture and deploy powerful stances you eventually feel powerful.

It's almost as though "playing pretend" through actions tricks your own mind to believe things.

Then as the attitude begins to strengthen, so do the actions, and this cycle continues on as long as actions, thoughts, and emotions stay aligned.

Dr. Ositelu breaks it down into four main components:

• Individual Motivation-Is the surgeon motivated to do this?
• Social Norms- What will others think? Do the surgeon's social norms encourage this action?
• Ability- Does the surgeon have the ability to take on this action? Can they afford to?
• Environment- Is the surgeon's environment optimized to enable this action?

A simple example of this psychology deployed in real life is what Dr. Ositelu did to enable the action of working out by addressing these four components.

• He exchanged his work backpack for a gym duffel bag, where he puts his laptop and office materials along with his gym clothes.
• He selected a gym right next to his work where he will consciously see a large reminder of his adopted action.
• At the gym, he sees others like him engaged in this social norm, except in a new environment.
• Everything was optimized to enable the momentum of the newly adopted attitude and ensure the action was taken.

Optimizing the context of working out (duffel bag) enhanced with the environment (proximity of the gym) multiplied these effects.

Change the context around the behavior and you enable action and multiply the staying power of the behavior.

So when Verb attempts to "democratize surgery" they must dig deep and explore a simple question;

What actions do they want the surgeon to take?

Then work backwards and change the context around the behavior.

Although Verb's technology isn't launching until 2020, the groundwork for shifting paradigms needs to start today.

Will that involve leveraging the Johnson and Johnson/Google brand?

Perhaps utilizing current surgeon influencers? Maybe educate the market what "democratizing surgery" means?

Those are all good tactics, but they're merely tiny pieces to a larger strategy that is needed.

That strategy, will dive into the deepest and darkest parts of human psychology and sociology, and I'm excited to be your guide in taking that journey, dear reader.

Hold on.

Presuading Surgeons Before Persuading Them

"Only use your super powers for good" - Uncle Joe

Dr. Robert Cialdini is a famous consumer psychologist who wrote the ground breaking book Influence: The Psychology of Persuasion.

Billionaire Charlie Munger (Warren Buffett's business partner) swears on this book, even saying to "buy this for all your children".

Yet three decades later, I still am shocked how many business professionals and top MBA students not only haven't read it, but they don't even know about it.

After a silent thirty years, Cialdini shocked the world when he published a groundbreaking and highly desired sequel to the classic just this past September, called "Pre-Suasion: A Revolutionary Way to Influence and Persuade".

The basic idea of pre-suasion is that by guiding preliminary attention strategically, it's possible for a communicator to move recipients into agreement with a message before they experience it.

Despite the lack of awareness around the power Cialdini's original work can teach, there are practitioners who have already deployed pre-suasion strategies in meaningful and impactful ways.

One example is "Precruit" by search executive Joseph Mullings of The Mullings Group. (*Note: I don't think it's a coincidence that he and his firm are regarded as the #1 firm in the world for medical device executive search.)

Pre-Suasion adds the dimension of time to the influence process, as there is a period before persuasion occurs where the mind is prepared subconsciously.

A "privileged moment for change" is what he calls the period.

So what separates effective communicators from truly successful persuaders?

This “privileged moment for change” prepares people to be receptive to a message before they experience it.

Optimal persuasion is achieved only through optimal pre-suasion.

In other words, to change “minds” a pre-suader must also change “states of mind.”

Recall Dr. Ositelu's observation on changing minds and actions?

Changing a state of mind is based around changing the context around the behavior.

Remember the third and latest iteration of Normalization Process Theory?

The theory of " Contexts" developed the analysis of agentic contributions by offering an account of centrally important structural and cognitive resources on which agents draw as they take action.

These aren't coincidences, dear reader.

The key behind all of this is to focus surgeons initially on concepts that are aligned associatively with the yet-to-be-encountered information.

This involves social psychology tactics that few can pull off.

Readied. Aim. Fire!

"The readiness is all." - Shakespeare

A key characteristic of mental activity is its elements don’t just fire when ready; they fire when readied.

After Verb has surgeons attend to a specific concept, those concepts closely lined to it enjoy a privileged moment within their minds, acquiring influence that non-linked concepts simply cant match.

A crucial insight to be gained from the underlying structure of mental activity has its origins in associations.

Just as amino acids are the building blocks of life, raw associations can be called the building blocks of thought.

Let's breakdown what pre-suasion approach Verb should take with their vision.

First, the opener (democratizing surgery) receives our attention.

It's something that is polarizing and not vague.

It is also incongruent, which is one of six principles that makes something psychologically compelling.

The second part of pre-suasion has closely associated secondary concepts that become more accessible in consciousness, which greatly improves the chance that we will attend and respond to the linked concepts.

This newly enhanced standing in consciousness elevates their capacity to color our perceptions, orient our thinking, affect our motivations, and thereby change our relevant behavior.

Like it or not, this was what helped Trump pull off the greatest political upset in American history.

In a past article, I dissected why this happened. (*Note - I have no affiliation to any political party. Im just a cynical observer of American politics)

"Make America Great Again" is something that is polarizing and not appealing to everyone.

However, it has a focus and caters to a specific tribe of people who.

Trump had a focused, consistent, and polarizing campaign that gained momentum overtime.

Hillary's downfall was changing messages that lacked consistency and focus. (Stronger Together, With Her, etc.)

Again, this has nothing to do with liking what happened and everything to do with learning why it happened.

Trump also stayed salient and always on the minds of voters.

The consistent, polarizing message "Make America Great Again" and associating his name and everything he has done and will do with being "great" and "beautiful", this had an affect on American minds.

Disagree? Like I said earlier, I don't like these things either, but I learn them.

It's not about liking what happens, but about learning how and why these things happen.

Sorry Johnson and Johnson. I need to use something painful from your past to drive this home.

Poisoned Tylenol and Winning the Lottery

It has been more than three decades since a consumer products company's worst nightmare became tragic reality for Johnson & Johnson.

The Chicago Tylenol Murders were a series of poisoning deaths resulting from drug tampering in the Chicago metropolitan area in 1982.

The victims had all taken Tylenol-branded acetaminophen capsules that had been laced with potassium cyanide.[4] A total of seven people died in the original poisonings.

Here's something that people completely missed:

Johnson and Johnson issued nationwide warnings and mass communication through the media specifically around two lot numbers:

Lot #2,880 and #1,910.

For some reason, the American public began to play these numbers in record highs in lotteries.

Three states even had to halt playing bets on the numbers because they reached the "maximum liability levels".

Cialdini's research revealed that with all the publicity around the numbers, they became focal in attention.

What is focal has causal properties - to have the ability to make events occur.

This occurred for two reasons:

1. The numbers were ordinary and not memorable.
2. They associated with a terrible event that also was widely publicized.

This tendency to presume what is focal is also causal holds sway too deeply, too automatically, and over many types of human misjudgment.

The market predicted that the Tylenol brand, which accounted for 17% of the company's net income in 1981, would never recover from the sabotage.

Two months later, Tylenol was headed back to the market, this time in tamper-proof packaging and bolstered by an extensive PR campaign. 

It illustrates the value of public relations and demonstrates why Johnson & Johnson is great at what they do.

The convergence of their expertise in medical devices and in pharmaceuticals has only strengthened over the decades, so I'm happy to see Johnson & Johnson partnering with Google in creating Verb Surgical.

Shutting Off the Outside World

The human egg has a shut off mechanism and sperm.

Once in, the egg closes off so the next one cant get in.

The human mind has the same tendency.

In Pre-suasion, all things that are not linked to the opener become suppressed in the consciousness, making them less likely than before to receive our attention and gain influence.

Rather than be readied for action, they get decommissioned temporarily. This leaves a window of time to take advantage of.

There’s an important limit to the pre-suasive effects. Attention to the first concept readies the second for influence in proportion to the degree of association between the two.

Cialdini tested this with his anti-littering campaign designed to discourage littering in public places.

Researchers placed flyers on cars in a parking lot with various messages: Don't litter, Recycle, Turn Off Lights, Go Vote, and Art Museum.

The identical primary concept (Don't litter) and strong link to the secondary concept (the ACTION of littering) was the strongest, thus resulting in the highest success rate of the experiment.

The strength of the association between the open concept and related concept will determine the strength of the pre-suasive effect.

Sparking Action and Lighting Behavior

Coincidentally, Verb Surgical’s name happens to be brilliantly picked.

We can see this pre-suasive effect in Intuitive Surgical's company. They were the first robotic system, and they wanted surgeons to engage as the robot was an extension of them.

It wasn't foreign. In fact, using a robot is "Intuitive".

Pre-suasion presented a lot of data that shows:

1. What is more accessible in the mind becomes more probable in action.
2. This accessibility is influenced by the informational cues around us and by our raw associations to them.

The key is to focus them initially on concepts that are aligned associatively with the yet-to-be-encountered information.

Provoking Revolution and Changing Culture

When devouring Pre-Suasion something surprised me, and that created a deeper cut into this article series on Verb "democratizing surgery".

Cialdini revealed that a seventh principle exists; Unity.

Cialdini defines "Unity" as a shared identity.

This shared identity can be with family, people from a similar backgrounds or location, and even with a product one helped create.

At first I thought unity is just the “liking” principle from his first book "Influence", which relies on shared attributes.

When you topple the status quo and start a revolution, you change culture.

History doesn't always repeat itself, but it definitely rhymes.

If Verb wants to make history, it needs to start playing a tune that has a rhyming resonance that speaks to a specific type of surgeon.

That will involve a marketing strategy that channels a mass desire among surgeons and then directing it in unity.

The unity of many mass movements is held together by one emotion; hate.

Our next article will focus on the social psychology of stirring up a surgical mass movement and how hate will serve as a vital tool in creating a revolution to democratize surgery.

Please leave your thoughts and questions below in the comments.

Disclaimer

This is a personal LinkedIn blog. The opinions expressed here represent my own and not those of my employer or any other company.

______________________________________________________________________

Omar M. Khateeb is an unorthodox and innovative marketing leader with a background in science and medicine. 

He publishes an article a week on LinkedIn, drawing from various sources.

His interests reside in sales psychology, neuromarketing, and self-development practices. He often reads 2-3 books a week and combines concepts to execute strategies in new ways.

Check out his virtual bookshelf here to find your next great read, and connect with him on LinkedIn, Twitter, or SnapChat.